|Beitragstitel||Asymptomatic periprosthetic joint infection of the hip with high-virulence pathogens: report of two cases|
We report two cases of periprosthetic joint infection (PJI) after total hip arthroplasty (THA) with highly virulent pathogens but asymptomatic clinical and radiological presentation over years despite the absence of treatment. There are no similar reports available in the literature.
A 27 year old female with severe anorexia underwent staged bilateral THA for avascular necrosis. 1 month postop on the left side she developed acute PJI with S. aureus. Low volume aspiration allowed no cell count. The patients anorexia was poorly controlled with impending liver failure and severe hyponatraemia. Revision surgery was not possible due to prohibitive general conditions. The patient refused antibiotic treatment. Over the next weeks the patient became afebrile and denied further symptoms. At the 1 year mark she is ambulating without discomfort. X-ray show well fixed components without signs for loosening.
A 74 year old obese and diabetic female underwent right sided multi stage revision THA for an acute polymicrobial PJI. 6 years later the patient complained about persistent right sided hip pain. Blood works were normal. Joint aspiration showed pathological cell count (226’300 leucocytes/µl) and grew S. lugdunensis. Revision surgery was scheduled but could not be performed due to an in-hospital fall which caused an open ankle fracture necessitating multiple procedures. After 3 months the patient was asymptomatic. Revision was therefore undefinitely postponed. 4 years later the patient still denies symptoms to her hip. X-ray show a well fixed cup. The uncemented stem shows a radiolucent line around its shoulder but has not subsided in 10 years. In absence of hip and/or thigh pain we conclude that the implants are properly integrated.
The cases described are neither representative for classic manifestation nor for state of the art final management of PJI.
The fact that high-virulence pathogens can colonize implants over time without causing symptoms or mechanical failure is a rarity so far and both cases need further observation. Both PJIs reported have not been treated surgically following standard guidelines because of adverse clinical circumstances. When surgery is not a viable option suppressive antibiotic therapy can be considered. Therapeutic abstinence however might be an alternative to long-term antibiotic suppression in selected cases, despite not being mentioned as an option in any guideline.